Author(s): Thomas Beyer. Published on January 4, 2016.

Community Coverage

As hospitals try to reduce costs related to readmissions and emergency department care, fire-based medical services get proactive in providing non-acute care. BY THOMAS BREYER

ON NEW YEAR'S EVE of 2007, the Phoenix metropolitan area was hit by a flu epidemic. Almost simultaneously, hundreds of people in the area descended on local hospitals for treatment, producing a dramatic impact on the area’s emergency safety net.

As any first responder knows, an overwhelmed emergency system can present a dangerous situation. The public health emergency in Phoenix and surrounding communities could have impacted vulnerable patients with chronic, comorbid conditions—people who do not typically fare well with exposures to respiratory illnesses—and they risked delays in accessing and receiving care. The emergency could also have affected patients with acute, time-critical injuries and illnesses, patients who also experienced delays and risked complicated recoveries as a result of exposure to influenza. There was also the worst-case scenario of the area being hit by another large-scale disaster, in which case the hospitals and emergency services system could have been completely incapacitated.

At one hospital in particular, in the neighboring community of Mesa, patients arrived en masse and quickly overwhelmed the emergency department. With no other alternatives, according to Dr. Gary Smith, medical director of the Mesa Fire and Medical Department, the hospital did what anyone else would do in a time of crisis: it called the fire department. Through a coordinated effort between the hospital and the Mesa Fire Department, the fire-based emergency medical services (EMS) providers assisted with the triage process and helped manage the crisis until the worst of it had passed.„

The flu epidemic did not resolve itself overnight, however, and the city needed a plan to manage the strain placed on its healthcare infrastructure. A plan was quickly formulated, and over a 100-day period the Mesa Fire Department and the hospital worked together to manage patients. The hospital provided a physician’s assistant and the fire department provided a firefighter/paramedic captain and a department vehicle. Together these caregivers responded in a non-emergency manner to patients with flu-like symptoms who had requested emergency medical assistance via the 911 system. The vehicle was staffed 12 hours a day, every day, and eventually made contact with nearly 1,000 patients whose medical needs were managed outside the hospital rather than in it. Among other things, that meant there was an increased availability of emergency response resources as well as more available hospital beds.

What happened in Mesa is a good example of community paramedicine, the term used for the emerging practice of non-emergency medical care provided outside of a hospital setting, usually in patients’ homes, by fire-based paramedics or emergency medical technicians. Also known as mobile integrated healthcare, community paramedicine programs are designed to address and manage a variety of healthcare-related issues such as low-acuity call types, better management of patients with chronic health conditions, and meeting the needs of patients who have selected 911 because they know of no other way to access medical help. Patients are not merely treated and released; the key concept to this emerging model of healthcare delivery is that patients are treated, managed, and educated. Services are intended to keep people out of hospital emergency rooms and thereby reduce healthcare costs while keeping emergency resources available for true emergencies.

First Responder closing ambulance to respond to an incident
​A proposed NFPA guide would provide benchmarks for a fire-based community healthcare program. ​Photograph: AP Wide World/Ed Andrieski

Such programs represent a dramatic reinvention of healthcare delivery in this country, where the fire department, rather than a hospital, is the central connector in a patient-centric system. NFPA’s EMS technical committee believes this is an ideal opportunity to become further engaged in this area, and is about to begin work on the development of a new community paramedicine document. While challenges remain for the broader development of these programs, they have already proven themselves effective in the healthcare realm and represent a key component in the ongoing evolution of the modern fire service.

Emerging need

The fire service has historically adopted change to meet the needs of the population. When there were dramatic increases in fire-related fatalities, injuries, and economic loss, the fire service was one of many partners working to improve fire safety and increase prevention practices. Similarly, fire departments across the nation have increased their levels of service to the public to address a variety of emerging issues, including hazardous materials response, technical rescue, terrorism, and active shooters.

In the area of fire-based EMS, fire departments, in cooperation with local hospitals and physicians, trained and deployed firefighters to respond to cardiac medical emergencies. As the needs of the population changed, fire-based EMS transitioned from cardiac care to trauma care to all-care. Unfortunately, and largely due to healthcare laws that require patients to be transported to hospitals to receive care, the hospital emergency department has become the one-stop shop for all illnesses and injuries, with EMS as the access point in many cases. This style of patient care delivery has not only impacted fire departments and the municipalities they serve, but has also led to a sharp increase in healthcare costs due to the high price of uncompensated care. However, few practices have been instituted to control demand and match patient need to the appropriate resources.

A complicating factor is access to routine healthcare, which has become more problematic for large segments of society, including people living in underserved urban cores. As a result, additional burdens are placed on hospital emergency departments as people seek care for acute conditions that could have been managed through a primary care doctor. The pressure on emergency departments is expected to increase in the coming years as more people have access to health insurance but limited access to primary care physicians.

Prehospital care delivered by EMS personnel is therefore attractive for a number of reasons, but there are legal impediments that may prohibit communities from utilizing it. In some cases, this type of care may require legislative changes to ensure that prehospital care providers can perform the care discussed within their scope of practice. Many states have limited the type of care these providers are permitted to perform to emergency response, interfacility transport, and care in the hospital setting.

This may be changing, however. At least 13 states have implemented legislation that allows prehospital care providers to practice community paramedicine, with several others either proposing legislation or creating legislation for pilot projects. There could be other ways of accomplishing this goal without reinventing the wheel. Sixteen states support a type of healthcare provider known as a community health worker, or CHW. The CHW’s scope of practice is to address certain population health needs and improve patient outcomes through individual patient contacts and information distribution. Some states even allow CHWs to perform patient assessments, including the use of point-of-contact lab work such as blood glucose assays and more. Ideally, CHWs are members of the community who are situated to contact a significant portion of the population. It’s hard to imagine a better-qualified group to do that than the fire service.

Putting it into practice

Despite the existing barriers, many fire departments have implemented community paramedicine initiatives—programs now exist in an estimated 110 communities nationwide.

The idea of utilizing EMS providers to manage healthcare has been discussed in the United States since the 1990s. The concept, which initially applied to rural areas, acknowledges that the more remote a location is, the less likely it is to have access to primary care providers. However, these medically underserved regions typically have some form of prehospital care providers that can act as “physician extenders” to meet some patient needs. With the signing of the Patient Protection and Affordable Care Act (PPACA) in 2010, numerous opportunities arose for fire-based EMS providers to become an integral part of healthcare, beyond emergency response.

At first, fire departments used the concept of community paramedicine to manage high-utilizer patients, direct patients to the most appropriate care, and assist patients in need with appropriate social services and charitable resources. In these early stages, the goal was to increase unit availability and steer certain patients away from a transport to a hospital emergency department. These practices allowed agencies to increase hospital bed availability and reduce demand on transport units, as well as on first responders.

First Responder in bedroom working with injured person
Read more on the many variations of community paramedicine.  Photograph: Ed Kashi/Corbis

As the concept of community paramedicine has evolved, though, forward-thinking leaders in the fire service have begun to consider how additional kinds „ of prehospital care providers might fit into the model, including healthcare providers not typically associated with 911 response. Many fire departments that provide community paramedicine services are starting to utilize EMTs, advanced EMTs, nurses, physician’s assistants, nurse practitioners, physicians, and other healthcare and social service providers, which includes faith-based and philanthropic groups. In Mesa, for example, the program has grown to involve other hospitals and utilizes nurse practitioners for care. It has also transitioned to a fire-based ambulance that acts as a mobile health clinic.

This integrated system of care means that community paramedicine can avoid the pitfalls associated with a siloed system of patient care. A community paramedicine system is not designed to be the replacement for primary care, chronic care, or the management of acute medical emergencies outside of the emergency department. It is a system that allows fire departments to act as the intersection of emergency care, primary care, social care, and public health, but not a system that is designed to encroach on the work of other healthcare providers and workers. Similarly, fire-based community paramedicine can act as a supplement to, or in partnership with, existing healthcare professionals.

Through a series of partnerships with other healthcare professionals and charitable organizations, fire departments are ideally situated to reach specific patient bases and match these patients with the appropriate care providers or resources, whether they be physical or social healthcare providers or both. Additionally, fire departments can be engaged to help manage patients in home healthcare situations, post-discharge care, and hospice care.

The program run by the Dallas Fire Department is an example of one that combines the models of integrated care and post-discharge. According to Norman Seals, deputy chief of the Dallas Fire Department, a few years ago department leadership began to notice the increase in demand on the EMS system and realized that the busier the system became, the more the quality and value of care would be impacted. The department made it a goal to manage the demand on the system, and began by identifying the city’s high-utilizer population as well as the community-based and health resources that could help manage these patients.

Initially the criteria for selecting high utilizers was based on an annual assessment of patient calls. But the department soon discovered that this led to an over-triage of patients and made the system inefficient. In many instances, patients with a high frequency of annual calls had experienced an issue that was self-limiting and only needed 911 with high frequency for a short period of time, and not in a manner that burdened the system. The department adopted a smaller assessment period and identified high utilizers as any patient who generates 15 responses within 90 days.

Patients who meet this criteria are asked if they would like to participate in a voluntary program that provides them with training on how to manage their own healthcare. The program matches the patient’s specific need to resources that can improve patient outcome as well as their quality of life. So far the program has enrolled 102 people, and the department has experienced a 90 percent reduction in high-utilizer demand. The department also has cooperative agreements with more than 40 healthcare, faith-based, and community-based programs to assist in managing the patients’ specific needs.

Challenges remain for community paramedicine: prehospital care providers in Mesa, for example, are limited by the scope of practice, which is why they must rely on nurse practitioners and physician’s assistants to provide certain types of care. In Dallas, the program is largely unable to address high utilizers with profound mental illness or substance abuse problems, due mainly to the scarcity of state funding for, and availability of, mental health resources. Although frequent callers with substance abuse problems are asked on their first contact if they will accept assistance, both profound mental health issues and substance abuse are generally exclusion criteria.

This year, NFPA’s EMS technical committee, with support from the Fire Protection Research Foundation, will begin work on a guide to assist the fire service in the development and implementation of benchmarks for a fire-based community healthcare provider program. The committee’s first meeting for the proposed NFPA 451, Guide for Fire-Based Healthcare Providers, will be held in January in Orlando, Florida. The meetings and progress of the committee can be followed at the document information webpage.

Efforts like these will help shape our focus going forward. It is likely that as community paramedicine becomes more prominent, providers will be able to connect patients to resources that not only address their immediate healthcare needs but can also improve outcomes and ensure positive long-term results. As the United States struggles to overcome the opioid epidemic, for example, fire-based EMS resources could provide needle-exchange programs that include resources for overcoming chemical dependency and HIV/AIDS prevention. However, fire service leadership must ensure that state rules and regulations are created to not only allow for this type of care but also provide means of compensation to fire departments that offer it. That leadership must also ensure that, in addition to determining community need, they engage the appropriate stakeholders for assistance in managing the needs of patient populations. Without legislative assurances and stakeholder engagement, successful community paramedicine programs will be difficult to achieve.

Thomas Beyer is director of fire and EMS operations at the International Association of Fire Fighters. He is studying community paramedicine and mobile integrated health as ways to improve patient outcomes and system management.
Top Illustration: James Steinberg